(PFF)

PERMOHONAN MENDUDUKI PEPERIKSAAN KELAYAKAN UNTUK MENGAMAL FARMASI

APPLICATION FOR QUALIFYING EXAM TO PRACTICE PHARMACY IN MALAYSIA

(Borang/ Dokumen yang perlu disertakan)

(Form / Documents to be attached)

SENARAI SEMAK UNTUK DIISI OLEH PEMOHON KEGUNAAN PEJABAT

(Sila tandakan √ ) (FOR OFFICE USE ONLY)
CHECKLIST TO BE COMPLETED BY APPLICANTS
(Please mark √)

Tidak Tarikh Terima

Ada Tiada
berkaitan
(Yes) (No)
(NA)

1. Borang Permohonan Peperiksaaan

Kelayakan Untuk Mengamal Farmasi Cop terima
yang lengkap diisi
Qualifying Examination for registration as a practising pharmacist
in Malaysia application form

2. Salinan Ijazah yang disahkan

Certified copy of degree

3. Salinan Sijil Pendaftaran Luar Negara Tarikh Lengkap :

yang disahkan (Jika Ada)
Certified copy of Overseas Registration Certificate (if any)

4. Salinan Kad Pengenalan / Disemak oleh:

Pasport yang disahkan
Certified copy of Identity Card/Passport Nama:

5. Alamat di Malaysia yang terkini Tarikh :

Current Address in Malaysia
Nota:
6. No. telefon yang boleh dihubungi
dan alamat emel
Contactable telephone number and email address

Dokumen tambahan bagi Ahli Farmasi bukan warganegara

Malaysia :
Additional documents for Non-Malaysian Pharmacist :
Masuk Data Dalam Komputer:
7. Salinan sijil perkahwinan & Permit Kerja
pasangan/sendiri yang disahkan Nama:
Certified copy of Marriage Certificate and work permit
of your own/spouse Tarikh :

8. Salinan bukti perolehan doctorate

yang disahkan (PhD) (Jika Ada)
Certified copy of doctorate award (PhD) (if any)

NOTA/Note:

1. Salinan sijil-sijil, ijazah atau dokumen lain yang berkaitan hendaklah disahkan oleh
Ahli Farmasi Berdaftar di Malaysia atau Pengamal Perubatan Berdaftar di Malaysia
dengan mencatatkan Nombor Pendaftaran dan Pengekalan Amalan Tahunannya.
Pengesahan dari Pegawai Kumpulan Pengurusan dan Profesional, Majistret, Jaksa
Pendamai juga boleh diterima.
Copies of certificates, degree or other relevant documents must be certified by a Malaysian Registered
Pharmacist or Malaysian Registered Medical Practitioner, with stated registration number and annual
practising retention number. Certification by a Professional Management Group of Government
Officer, a Magistrate, and a Justice of Peace are also acceptable.

2. Pihak Urusetia berhak menolak permohonan jika tidak lengkap dan dikembalikan
kepada pemohon.
The secretariat has the right to reject any incomplete application and shall be returned to the
applicant.
Qualifying Exam to Practice Pharmacy April 2017
 LEMBAGA FARMASI MALAYSIA
KEMENTERIAN KESIHATAN MALAYSIA
PHARMACY BOARD MALAYSIA
MINISTRY OF HEALTH MALAYSIA

SETIAUSAHA
Lembaga Farmasi Malaysia
Bahagian Amalan & Perkembangan Farmasi
Kementerian Kesihatan Malaysia
Lot 36, Jalan Universiti
46350 PETALING JAYA, SELANGOR

Tuan / Sir,

PERMOHONAN UNTUK MENDUDUKI PEPERIKSAAN KELAYAKAN UNTUK MENGAMAL FARMASI

BAGI BULAN...........................................

APPLICATION FOR THE QUALIFYING EXAM TO PRACTICE PHARMACY IN MALAYSIA FOR THE MONTH OF: …………………….

1. BUTIR-BUTIR PEMOHON (Personal Particular)

Nama :
Name :

Alamat Surat Menyurat:

Postal Address :

Poskod: Negeri:
Postcode: State:

No. Kad Pengenalan:

Identity Card No:

Umur: Tarikh Lahir: Warganegara:

Age: Date of Birth: Citizenship:

Qualifying Exam to Practice Pharmacy April 2017

 Tandakan () Tick ()

Jantina Taraf Perkahwinan

Sex Maritial Status

Perempuan Bujang
(Female) (Single)

Lelaki (Male) Berkahwin

(Married)

No. Telefon: No. Telefon Bimbit:

Telephone No: H/Phone No.:

No. Faks (Jika ada)

Fax No. (If available)

E-mail: ………………………………………………………………………………...

2. UNTUK DIISI OLEH WARGA ASING (To Be Filled By Non-Malaysian)

No. Pasport (Jika Bukan Warganegara): Tarikh Tamat pasport:

Pasport No Expiry Date:

No. Pendaftaran Perkahwinan: Negara Didaftarkan:

Marriage Registration No. Country Registered:

No. Permit Pekerjaan (Jika ada):

Work Permit No. (If available)

Tarikh Tamat Permit Kerja:

Work Permit Expiry Date:

3. BUTIR-BUTIR SUAMI/ISTERI (JIKA BERKAITAN): [Spouse's Particulars (If Applicable)]

Nama Suami/Isteri:
Name of Spouse:

No. Kad Pengenalan:

Identity Card No:

Qualifying Exam to Practice Pharmacy April 2017

 No. Pasport: Warganegara:
Pasport No: Citizenship:

Pekerjaan:
Ocupation

Alamat Majikan:
Employer:

Poskod: Negeri:
Postcode: State:

No. Telefon: No. Telefon Bimbit : (jika ada):

Telephone No H/Phone No (if available)

No. Faks (jika ada)

Fax No. (If available)

E-mail (Jika ada): ...........................................................................................

E-mail (If available)

4. BUTIR-BUTIR KELAYAKAN :( Qualification)

Kelayakan/kelulusan: Tarikh Diperolehi:

Degree (Date graduated)

Tandakan () (Tick)

a. Program Berkembar (Twinning)/Francais

b. Sepenuh Masa Di Malaysia (Full Time in Malaysia)

c. Sepenuh Masa Di Luar Negara (Full Time Overseas)

Nama Universiti/Institusi:
University

Qualifying Exam to Practice Pharmacy April 2017

 5. TARIKH MENJALANI LATIHAN: Housemanship/Pupillage

5.1 Tempat/Alamat Latihan:

Place/Address

Tarikh Mula: Tarikh Tamat:

Date Started: Date Finished:

5.2 Tempat/Alamat Latihan:

Place/Address

Tarikh Mula: Tarikh Tamat:

Date Started: Date Finished:

6. BUTIR-BUTIR PENDAFTARAN SEBAGAI AHLI FARMASI DI LUAR NEGARA (Jika Ada):

(If registered in other country)(If applicable)

No. Pendaftaran Negara Didaftarkan

Registration No: Country Registered:

Tarikh diperolehi:
Date:

Tarikh: .................................. ........…….................................

(Date) (Tandatangan Pemohon)
(Applicant’s Signature)

Qualifying Exam to Practice Pharmacy April 2017

 PANDUAN UNTUK PEMOHON
1. Borang yang lengkap diisi hendaklah dialamatkan kepada:

SETIAUSAHA
Lembaga Farmasi Malaysia
Bahagian Amalan & Perkembangan Farmasi
Kementerian Kesihatan Malaysia
Lot 36, Jalan Universiti,
46350 Petaling Jaya,
Selangor, Malaysia

2. Borang permohonan boleh diperolehi daripada:

a) Lembaga Farmasi Malaysia (seperti alamat di atas)
b) Laman sesawang www.pharmacy.gov.my

3. Sebarang pertanyaan boleh diajukan kepada Lembaga Farmasi Malaysia

dengan menghubungi

Puan Hanisah Shafie (hanisah.shafie@moh.gov.my / 03-7841 3383)

atau

Puan Nur Husni Hamid (husni.hamid@moh.gov.my / 03-7841 3317)

GUIDELINES FOR APPLICANTS

1. A completed form must be sent to:

SECRETARY
Pharmacy Board Malaysia
Ministry of Health Malaysia
Lot 36, Jalan Universiti,
46350 Petaling Jaya,
Selangor, Malaysia

2. The application form can be obtained from:

a) Pharmacy Board Malaysia (as the above address)
b) Website (www.pharmacy.gov.my)

3. For further inquiries, please contact Pharmacy Board Malaysia:

Puan Hanisah Shafie (hanisah.shafie@moh.gov.my / 03-7841 3383)

or

Puan Nur Husni Hamid (husni.hamid@moh.gov.my / 03-7841 3317)

Qualifying Exam to Practice Pharmacy April 2017